The reporting required by CMS to fulfill Mandatory Insurer Reporting (MIR) requirements went live on January 1, 2011. The processes to achieve full compliance are complex and require extensive technology, data scrubbing and timely submission for entities that must report claims. Many reporting entities have encountered difficulties, including significant issues with data validation—resulting in either not reporting eligible claims or unnecessarily reporting ineligible claims to CMS. These data issues can increase risk for payers, as data reported with errors can result in temporary suspension of reporting with CMS, increasing the risk of non-compliance penalties. Following is a sample of some of the challenges RREs face in meeting compliance and the potential results of these issues.
On May 17, 2011, the Centers for Medicare & Medicaid Services (CMS) issued a revised alert providing information pertaining to Non-Group Health Plans (NGHP), classified as Responsible Reporting Entities (RREs) under Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA).
The revised alert provided RREs the following additional information regarding revisions being made to validation of tax identification numbers (TINs) and related name and address information effective October 1, 2011.
On April 5, 2011, the Centers for Medicare & Medicaid Services (CMS) issued an alert providing information pertaining to the upgrade of Query Files and HIPPA Eligibility Wrapper (HEW) Software to ASC X12 270/271 Version 5010A1 under Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA). The alert addressed the implementation and scheduled upgrade to the Eligibility Inquiry/Response set used for Section 111 Query Files and the HEW translation software.
This upgrade affects all Section 111 query files exchanged with the CMS Coordination of Benefits Contractor (COBC). Differences between Versions 4010A1 and 5010A1 are minor and adoption of Version 5010A1 should not be difficult. The upgrade to the new version of HEW software (Version 3.0.0) should be completed by January 1, 2012 by all Responsible Reporting Entities (RREs) using the current HEW software. Testing of the new version is recommended but not required.